BRIEF REPORT Smith-Lemli-Opitz syndrome and inborn errors of cholesterol synthesis: summary of the 2007 SLO/RSH Foundation scientific conference sponsored by the National Institutes of Health Louise S. Merkens, PhD1, Christopher Wassif, MS2, Kristy Healy, RN, CCRC1, Anuradha S. Pappu, PhD3, Andrea E. DeBarber, PhD3, Jennifer A. Penfield, MS, PA-C1, Rebecca A. Lindsay, BA4, Jean-Baptiste Roullet, PhD1, Forbes D. Porter, MD, PhD2, and Robert D. Steiner, MD1,5 Abstract: In June 2007, the Smith-Lemli-Opitz/RSH Foundation held a tive research projects that would ultimately improve our under- scientific conference hosted jointly by Dr. Robert Steiner from Oregon standing and treatment of SLOS and other inborn errors of Health & Science University and Dr. Forbes D. Porter from The Eunice cholesterol synthesis. Kennedy Shriver National Institute for Child Health and Human De- Several of the scientists also participated in the concurrent velopment, National Institutes of Health. The main goal of this meeting Smith-Lemli-Opitz/RSH Foundation family conference. These was to promote interaction between scientists with expertise in choles- family sessions occur every 2 years as a forum for education of terol homeostasis, brain cholesterol metabolism, developmental biol- families with affected children about SLOS and dealing with ogy, and oxysterol and neurosteroid biochemistry, clinicians research- children with a chronic disease. They are also an opportunity for ing and treating patients with Smith-Lemli-Opitz syndrome, the patient SLOS families to meet and network. The families were invited support organization and families. This report summarizes the presen- to ask questions and express concerns to a panel of physicians, tations and discussions at the conference, represents the conference psychologists, dietitians, and scientists currently working in the proceedings, and is intended to foster collaborative research and ulti- diagnosis and management of patients with SLOS. This impor- mately improve understanding and treatment of Smith-Lemli-Opitz syn- tant event offered parents the opportunity to discuss current drome and other inborn errors of cholesterol synthesis. Genet Med 2009: research with experts in the field. 11(5):359–364. The keynote speaker for the conference was Dr. G. Stephen Tint, who, in 1993, first identified the cholesterol biosynthetic Key Words: Smith-Lemli-Opitz syndrome, cholesterol, hedgehog pro- defect causing SLOS.1 The keynote speaker award is presented teins, neurosteroids, cholesterol transport, mevalonate kinase defi- as an honor to an individual with outstanding commitment to ciency, Niemann-Pick type C, oxysterols, CHILD syndrome the field and is sponsored by the Smith-Lemli-Opitz/RSH Foun- dation Board. Dr. Tint’s contributions and service to patients with SLOS and to their families are recognized internationally, n June 2007, the Smith-Lemli-Opitz/RSH Foundation held a and the hosts and sponsors of the conference were delighted that Iscientific conference hosted jointly by Dr. Robert Steiner from he was able to participate in this capacity despite recent retire- Oregon Health & Science University (OHSU) and Dr. Forbes ment from his academic position. D. Porter from The Eunice Kennedy Shriver National Institute SLOS is the most common among a group of disorders with for Child Health and Human Development (NICHD), National multiple malformations and mental retardation due to defects in Institutes of Health. The main goal of this meeting was to cholesterol synthesis. Mutations in the gene encoding the last promote interaction between scientists with expertise in choles- enzyme, 7-dehydrocholesterol reductase, (DHCR7), result in terol homeostasis, brain cholesterol metabolism, developmental low cholesterol and elevated concentrations of an abnormal biology, and oxysterol and neurosteroid biochemistry, clinicians sterol, 7-dehydrocholesterol (7DHC) in tissues and blood. studying and treating patients with Smith-Lemli-Opitz syn- SLOS has an observed incidence of at least 1 in 30,000, but drome (SLOS), patient support organization, and families. It based on carrier rates it may be more common. The SLOS was anticipated that these interactions could lead to collabora- phenotype includes various congenital malformations, mental retardation, and distinctive autistic-like behavior. This group of human syndromes provides a unique opportunity to study the From the 1Department of Pediatrics, Oregon Health & Science University, Portland, Oregon; 2Heritable Disorders Branch NICHD, NIH, DHHS, Be- role of cholesterol synthesis and homeostasis in health, devel- thesda, Maryland; Departments of 3Physiology and Pharmacology, 4Neuro- opment, and behavior. SLOS may also turn out to be a treatable surgery, and 5Molecular and Medical Genetics, Child Development and form of mental retardation if researchers are successful in their Rehabilitation Center, Oregon Clinical and Translational Research Center, quest for effective treatments. Finally, learning more about and Doernbecher Children’s Hospital, Oregon Health & Science University, cholesterol synthesis and metabolism by studying SLOS and Portland, Oregon. related disorders will shed light on the more common disorders Louise S. Merkens, PhD, Department of Pediatrics, Oregon Health & Sci- with hypercholesterolemia. ence University (OHSU), Mail Code CDRC, 707 SW Gaines Road, Portland, OR 97239. E-mail: [email protected]. Disclosure: The authors declare no conflict of interest. CONFERENCE HIGHLIGHTS Submitted for publication December 3, 2008. Sterols, development and the hedgehog pathway Accepted for publication December 23, 2008. Hedgehog (Hh) proteins are signaling molecules that are DOI: 10.1097/GIM.0b013e31819b246e secreted and function in diverse patterning of the development Genetics IN Medicine • Volume 11, Number 5, May 2009 359 Merkens et al. Genetics IN Medicine • Volume 11, Number 5, May 2009 of body parts during embryogenesis. Hh proteins can promote In SLOS, the last enzyme of the cholesterol pathway is cell proliferation, prevent apoptosis, and act as morphogens that inhibited resulting in low concentrations of cholesterol and high specify cell responses depending on gradient tissue distribution. concentrations of 7DHC. To reduce synthesis of abnormal ste- As described by Dr. Beachy, newly synthesized Hh proteins rols, high-cholesterol diets and high-cholesterol diets with statin undergo a series of posttranslational processing that involves drugs (inhibitors of 3-hydroxy-3-methyl-glutaryl-CoA reduc- covalent modification by cholesterol resulting in release of tase) are being administered to determine their effectiveness as active signal with covalent cholesteryl adduct.2 Hh proteins are treatment. It is important to evaluate their effects on the cho- the only known proteins that are covalently modified by cho- lesterol synthesis pathway as well as on the absorption of lesterol. Even though 7DHC may be substituted for cholesterol dietary cholesterol. Complex techniques using stable isotopes in the activation of Hh proteins, reduction of total sterols, and gas chromatography-isotope ratio mass spectrometry8 are especially during in utero development, could interfere with Hh being used by Dr. Jones to study metabolism in children under- protein signaling and function. In addition to its role in the going these treatments. Preliminary results show that high- biogenesis of the Hh protein, cholesterol has an important role cholesterol diet with or without statins decreases the fractional in response to the Hh protein signal. Cholesterol depletion limits cholesterol synthesis compared with very low cholesterol diet. the ability of cells to respond to the Hh protein. In addition, there is a trend in the high-cholesterol diet with In human CHILD syndrome and in bare patches (Bpa) mice, statins to decrease dietary cholesterol absorption compared with there is a mutation in a sterol dehydrogenase (NSDHL) in- high-cholesterol diet without statins.9 volved in cholesterol biosynthesis that results in defects in one Any therapies for SLOS involving dietary cholesterol need to or more developmental signaling pathways leading to male take into account the extent of cholesterol absorption from the lethality, as described by Dr. Herman. In several Bpa alleles, the intestines. There are many factors that have the potential to male lethality results from placental insufficiency.3,4 However, affect cholesterol absorption; these include genetic factors, bil- in vitro studies have shown that 7DHC, desmosterol, and 7␤- iary cholesterol secretion, and conversion of cholesterol to bile hydroxyl cholesterol can substitute for cholesterol in processing acids. In addition, there are quantitative and qualitative differ- domain-mediated transfer reactions. Dr. Herman and coworkers ences in bile acids. Effects of bile acids were reviewed by Dr. have demonstrated expression of the ligand Indian hedgehog Heubi. Some bile acids have no effect on cholesterol absorption, and the PTCH1 hedgehog receptor in mouse placenta. Affected whereas others increase cholesterol absorption. It has also been placentas from the mutant mouse strain, NsdhlBpa-8aH, show shown that cholesterol absorption is dependent on luminal bile decreased Hh signaling proteins in recipient placental cells of acids and micellar solubilization.10 In SLOS, urinary bile acids the allantoic mesoderm.4 have been shown to be reduced compared with healthy chil- dren.11 Minimal information is available about luminal bile acid Effects of changes in